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ICU infections basis, diagnosis, and prevention:

DEFINITIONS :

DEFINITIONS NOSOCOMIAL INFECTION : An infection acquired in a patient in a hospital or other healthcare facility in whom it was not present or incubating at the time of admission or the residual of an infection acquired during a previous admission. Dr.T.V.Rao MD 2

BACKGROUND of hospital infections:

Nosocomial infections have been recognized for over a century as a critical problem affecting the quality of health care and a principal source of adverse healthcare outcomes. BACKGROUND of hospital infections Dr.T.V.Rao MD 3

Risk of Infections in ICU :

Risk of Infections in ICU Patients hospitalized in ICUs are 5 to 10 times more likely to acquire nosocomial infections than other hospital patients . The frequency of infections at different anatomic sites and the risk of infection vary by the type of ICU, and the frequency of specific pathogens varies by infection site. Contributing to the seriousness of nosocomial infections, especially in ICUs, is the increasing incidence of infections caused by antibiotic-resistant pathogens Dr.T.V.Rao MD 4

The obvious focus:

DEVICE RELATED NOSOCOMIAL INFECTION :

DEVICE RELATED NOSOCOMIAL INFECTION A device-associated infection is an infection in a patient with a device (i.e., central line, ventilator, or indwelling urinary catheter) that was in use within the 48-hour period before onset of infection. If the interval since discontinuation of the device is longer than 48 hours, there must be compelling evidence that infection was associated with device use. Dr.T.V.Rao MD 12

ICU Care is more Invasive :

ICU Care is more Invasive More invasive life lines and procedures including surgeries Longer length of stay More IV and parenteral drugs More tube feeding and Parenteral nutrition More ventilation Dr.T.V.Rao MD 17

Managing fever in ICU patients:

21 Managing fever in ICU patients Fever in the ICU can have many infectious and noninfectious etiologies Crucial to identify the precise cause as some of the conditions in each groups are life-threatening, while others require no treatment “Routine fever work-up” not cost-effective If initial evaluation shows no infection, antibiotics should be withheld Empiric antibiotics may be started in the unstable patient, but stopped if infection is not evident later Dr.T.V.Rao MD

DEVICE RELATED NOSOCOMIAL INFECTION :

DEVICE RELATED NOSOCOMIAL INFECTION A device-associated infection is an infection in a patient with a device (i.e., central line, ventilator, or indwelling urinary catheter) that was in use within the 48-hour period before onset of infection. If the interval since discontinuation of the device is longer than 48 hours, there must be compelling evidence that infection was associated with device use. Dr.T.V.Rao MD 22

Prevention of CR-BSI:

Prevention of CR-BSI Written Protocol Must be performed by trained staff according to written guidelines Sterile procedure Sterile gown, Sterile gloves, Sterile large drapes Don't shave the site Hand disinfection With an antiseptic solution eg Chlorhexidine gluconate Dr.T.V.Rao MD 25

Basic policies in microbiological diagnosis of ICU infections:

Criteria for Diagnosis:

Criteria for Diagnosis fever . cough. development of purulent sputum, in conjunction with radiologic evidence of a new or progressive pulmonary infiltrate. a suggestive Gram stain, and positive cultures of sputum, tracheal aspirate, pleural fluid, or blood . Dr.T.V.Rao MD 31

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Dr.T.V.Rao MD 32

How To Diagnose?:

How To Diagnose ? A positive result of semi quantitative Culture ( 15 CFU per catheter segment ) Maki D, et al NEJM 1977;296:1305 or quantitative ( 10 2 CFU per catheter segment ) catheter culture, whereby the same organism isolated from a catheter segment and a peripheral blood sample Simultaneous quantitative cultures of blood samples with a ratio of 5 : 1 (CVC vs. peripheral) Differential time to positivity :positive result of culture from a CVC is obtained at least 2 hr earlier than is a positive result of culture from peripheral blood ) Dr.T.V.Rao MD 33

Remember………….:

If You put a central line in a patient with documented Bacteremia, then later next day somebody may obtain a blood culture from both the central lien and from periphery, >>>>>>> a positive blood culture from both sites, does not mean that the central lien is the source. Remember…………. Dr.T.V.Rao MD 34

Dealing with Staphylococcus Aureus :

Dealing with Staphylococcus Aureus REMOVE the central line . Systemic antibiotics for minimal 14 days. Failure to clear bacteremia within 72 hours Or patient with high risk for endovascular infection or having prosthesis may be indicative for longer 3-6 weeks of treatment. TTE or TEE are strongly advised. Blood Culture should be repeated during therapy and1-2 weeks after completion of therapy, looking for relapses.

Coagulase Negative Staphylococci:

Coagulase Negative Staphylococci CVC can be retained, if necessary, in patients with uncomplicated, catheter-related, bloodstream infection. If the CVC is retained, patients should be treated with systemic antibiotic therapy for 7 days. Treatment failure is a clear indication for removal of the catheter .

A Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter Withdrawal CID march 2007:

A Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter Withdrawal CID march 2007 Conclusions. CR-BSI can be assessed without catheter withdrawal in patients without neutropenia or blood disorders who have catheters inserted for a short time and are hospitalized in the intensive care unit. Because of ease of performance, low cost, and wide availability, we recommend combining semi quantitative superficial cultures and peripheral vein blood cultures to screen for CR-BSI , leaving differential quantitative blood cultures as a confirmatory and more specific technique . Dr.T.V.Rao MD 37

Do not treat colonized central lines get guided by microbiology reports:

A central line is removed and it is growing less than 15 CFU. Patient is not septic and blood Culture is negative. >>> No indication to treat the infected or colonized central line . Do not treat colonized central lines get guided by microbiology reports Dr.T.V.Rao MD 38

Problems with air sampling has limitations ???:

Incubation period of IPA unknown Estimates vary from 48 hours -3 months Geographical and seasonal variation in spore counts and predominant species Variable efficiency of different air samplers May not take account of surface contamination Settle plates, contact plates, honey jars Problems with air sampling has limitations ???

New Frontiers on increasing ICU infections:

New Frontiers on increasing ICU infections Emphasis on patient safety Move from inpatient to outpatient environment Increase in population age Persons >65yo numbered 36 million in 2004 and by 2030 there will be 72 million Increase in antimicrobial resistance (e.g., MRSA) Dr.T.V.Rao MD 40

Strategy for Prevention:

Strategy for Prevention Hand washing Use gloves to prevent contamination of the hands when handling respiratory secretions Wear gloves and gowns (contact precautions) during all contact with patients and fomites potentially contaminated with respiratory secretions Use aseptic technique Dr.T.V.Rao MD 41

Strategy for Prevention:

Strategy for Prevention Clean and decontaminate all equipment after use Sterilise or use high-level disinfection for all items that come into direct or indirect contact with mucous membranes Rinse and dry items that have been chemically disinfected Package and store items to prevent contamination before use Keep environment clean, dry and dust free Dr.T.V.Rao MD 42

Can we control ICU Infections:

Can we control ICU Infections The key to control of antibiotic-resistant pathogens in the ICU is rigorous adherence to infection control guidelines and prevention of antibiotic misuse. Antibiotic restriction policies clearly result in reduced drug costs. Evidence suggests that reducing use of certain antibiotics may lead to a decreased prevalence of antibiotic-resistant pathogens: vancomycin, VRE ; gentamicin, gentamicin-resistant Gram-negative bacilli; and, ceftazidime, Gram-negative Dr.T.V.Rao MD 49

Wish win the problem face the challenges:

Wish win the problem face the challenges Increase infection control resources are a win-win-win investment Reduced patient morbidity and mortality Net cost savings to institution, society and patient Improve patient satisfaction From the standpoint of the hospital and society, the benefits exceed the costs Hospitals should support a ratio of ICP per beds of 1:150 Dr.T.V.Rao MD 50

Microbes on skin play a major role skin disinfection a major preventive measure:

The major cause of infection during the first weeks of indwelling time is from skin microorganisms. Rannem, et. al. , 1990 Maki, et. al. , 1991 Maki (review), 1994 Widmer (review), 1997 Microbes on skin play a major role skin disinfection a major preventive measure

Chlorhexidine Skin Antisepsis:

Chlorhexidine Skin Antisepsis Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% isopropyl alcohol. Pinch wings on the applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad. Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. Allow antiseptic solution time to dry completely before puncturing the site (~ 2 minutes).

An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med Pronovost P, et al: 355(26):2725-2732, 2006 (1) hand washing, (2) use of full-barrier precautions during placement of catheters, (3) cleansing of the skin with chlorhexidine, (4) use of sites other than the femoral vein when possible , (5) removal of catheters that were no longer needed. The analysis included almost 2000 ICU-months and >375,750 catheter-days of data .

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WARNING Nosocomial Infections in ICU are Waiting Dr.T.V.Rao MD 56

Be kind to your patients REMEMBER ONE THING:

Be kind to your patients REMEMBER ONE THING PLEASE WASH YOUR HANDS

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Dr.T.V.Rao MD 58 Programme created by Dr.T.V.Rao MD for Health care Workers in the Developing world Email doctortvrao@gmail.com